GW1-2022-09477_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. C
1.Well Contractor Information: �
Ricky Corriher
WellConnactorName mom TO DESCRIPTION
2464-A
flIL oft.
, ft. it I
NC Well Contractor Certification Number -- t
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMEM TffiCKNIM
ft fL I in
CompanY Name. a �� '
2.Well Construction Permit#: J 60 FROM To MAMMAL1fficlaOrss MnTsxu►L
List aU applicable well construction permits(l.e-u1C.County,slate,Variance,eta) +1_ ' % fL 6 1/8 in SDR-21 PVC
3.Well Use(check well use): &
Water Supply Welh FROM TO DIAMETER _SI.OTSEZE TffiCIQO SS MATERIAL
❑Agricultural ❑ ipaUPnblic ft ft
❑Geothermal(Heating/Cooling Supply) esideatial Water Supply
(single) ft ft. in
❑lndustriaVCommimiai ❑Residential Water Supply(shared)
❑Iri 'on ❑Wells>100,000GPD FROM TO MATERIAL EMPLACENffiVTMEfHOD&AMOUNT
Non-Water Supply Well: 0 22 tL Bentonite Hole Plug
OMonitoring ❑R=very fL M f
Injection well: - ft M
❑Aquifer Recharge Mroundwater Rem ediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM SAC M-MMETSOD
❑Aquifer Test ❑Stormwater Drainage M ft `
❑Experimental Technology QSubsidenoe Control
�• ft ft
(jGeothemral(Closed Loop) ❑Tracer FROM TO a DESCRUMON color,hardnem sop/ slue ern
QGeothermal eatiurg�Cooling Return) ❑Other(explain ands#21 Rema:iss) [ram ft ft w
4.Date Well(s)Completed: -A-99N Well ED#
Sa.Well Location:
LLC
Facility/Owner Name
Facility (if applicable�X
fL ft
ft- fL
64 A: ft
Physical Addtas.City.and Zip is J
i C;y Parcel Identification No.(FIN) i, �Si.�il s Q1r
5b.Latitude and longitude in degrees/minatedsedonds or decimal degrees:
(if well field;one LI%ng is sufficient) s i 22.�Ccatio
3563 N800 W
6..Is(are)the well(s): ermanelit or• ❑Tempora:(o
Signature of ed Well Contractor Dula
iS v signing this form,I ha abv certiiftt t the—U(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes I or 1 SA NCAC 02C_0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
lfWs is a repair,fill out brawn well construction information and mTlain the nature of the of this record has been provided to the%eff owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
conshvction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilloth 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L (ft)
For multiple wdk lbt all depths ifdiffereM(example-3Q200'and 2 100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original'form to Division of Water Resources (DWR),
10.Static water level below top of casing: (1) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casin&use"+" I - •
6" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC .
11.,Borehole diameter: (�) pro , alei ).
Program,1636 MSC R gh NC 27699-1636'
12 Well construction method:Air Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health deppppartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For water Wells prodnrinb over 300,000 GPD:Copy to DWR,CCPCUA
AI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
132.Yield(gpm) 3 Method of test: �
13b.Disinfection thn.SterileneAmount
C /
Form FiW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018